The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?
Impaired perineal skin integrity
Protein-calorie malnutrition
Pain related to abdominal cramping
Fluid and electrolyte imbalance
The Correct Answer is D
A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.
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Related Questions
Correct Answer is D
Explanation
A. Prepare the client for a CT scan is not the first priority in this case. A CT scan might be considered if there is suspicion of complications like a kidney stone or abscess, but it is not the first intervention.
B. Begin broad spectrum antibiotics could be considered if a urinary tract infection (UTI) is suspected, but obtaining urine samples for culture and urinalysis is necessary first to confirm the diagnosis and guide antibiotic therapy.
C. Insert a Foley catheter is not indicated unless the patient is unable to void or there is a need for continuous monitoring of urine output, but it is not the first step.
D. Obtain samples for urine culture and urinalysis is the first step to confirm the diagnosis of a urinary tract infection (UTI) and determine the appropriate treatment. This will help guide the selection of antibiotics.
Correct Answer is B
Explanation
A. Decreased urine output is not directly associated with elevated potassium levels. It is more commonly linked to renal failure or dehydration.
B. Hyperkalemia (high potassium levels) can lead to ascending muscle paralysis due to its effects on the neuromuscular system. Potassium is critical for proper muscle function, and elevated levels can disrupt the electrical impulses needed for muscle contraction, potentially causing paralysis.
C. Hypoglycemia is unrelated to elevated potassium levels. It is more often associated with insulin use, inadequate food intake, or certain medical conditions.
D. Ascites is fluid accumulation in the abdomen, usually caused by liver disease or heart failure, and is not a direct complication of hyperkalemia.
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